Review articleBody fluid abnormalities in severe hyperglycemia in patients on chronic dialysis: review of published reports
Introduction
Dialysis-associated hyperglycemia (DH) causes potentially different solute and fluid disturbances from hyperglycemia developing in patients with preserved renal function because it is not complicated by large osmotic diuresis. Hyperglycemia should cause hypertonic states in both patients on dialysis and those with preserved renal function. However, unlike severe hyperglycemia in preserved renal function, which routinely causes clinically significant extracellular (EC) volume deficits, DH causes EC expansion. The baseline status of EC volume is theoretically a major determinant of the degree of both hypertonicity and EC volume expansion in DH, with edematous patients predicted to have greater hypertonicity and greater EC hypervolemia than euvolemic or hypovolemic subjects with the same degree of hyperglycemia (Tzamaloukas et al., in press).
In this report, we analyzed published reports on DH. We addressed three questions: (a) Do laboratory findings conform with theoretical predictions of solute and fluid abnormalities in DH? (b) Are specific predictions of the magnitude of body solute and fluid abnormalities in DH translated into clinical manifestations? (c) Do abnormalities in tonicity and EC volume differ between DH and hyperglycemia developing in patients with intact renal function?
The level of evidence of reports on severe hyperglycemia tends to be low because such reports are routinely retrospective and observational. With this proviso in mind, we analyzed published reports of severe DH and compared their findings on disturbances in body solute and fluids to those of major published studies in patients with preserved renal function and either diabetic ketoacidosis (DKA) or nonketotic hyperglycemia (NKH). Based on this analysis, we developed a treatment plan for DH.
Section snippets
Tonicity and related clinical manifestations upon presentation with hyperglycemia
Osmolality and tonicity are related but not synonymous. Serum osmolality is determined by the sum of all solutes in the serum, while tonicity, or effective osmolality, is the part of total osmolality contributed by EC solutes having difficulty crossing cell membranes and therefore causing (when their EC concentration changes) steady-state fluid shifts between the EC compartment and the intracellular (IC) compartment. A high urea concentration is routinely encountered in DH (Tzamaloukas et al.,
EC volume in DH
Table 5 shows fractional increases in EC volume at the peak of hyperglycemia {(ΔV/V1)/Δ[Glu]} calculated from the change in serum sodium concentration during the correction of hyperglycemia with insulin infusion only in the studies shown in Table 4. There is consistency between the different studies. In a hypothetical euvolemic patient with 14 l of euglycemic EC volume who develops a 66.7-mmol/l (1200 mg/dl) increase in serum glucose concentration, the calculated increase in EC volume using the
Acknowledgment
This work was supported by the New Mexico VA Health Care System.
References (80)
- et al.
Diabetic ketoacidosis and hyperglycemic hyperosmolar nonketotic syndrome
Endocrinology and Metabolism Clinics of North America
(2000) - et al.
Myocardial dysfunction without coronary artery disease in diabetic renal failure
American Journal of Cardiology
(1979) - et al.
Acid–base and electrolyte disturbances in patients with diabetic ketoacidosis
Diabetes Research and Clinical Practice
(1996) - et al.
Hyperosmolar non-ketoacidotic coma in diabetes
Lancet
(1966) - et al.
Hyponatremia: Evaluating the correction factor for hyperglycemia
American Journal of Medicine
(1999) - et al.
Interdialytic weight gain correlates with glycosylated hemoglobin in diabetic hemodialysis patients
American Journal of Kidney Diseases
(1994) - et al.
Hyperosmolar hyperglycemic nonketotic syndrome
American Journal of Medicine
(1984) - et al.
Evolving concepts in the quantitative analysis of the determinants of the plasma water sodium concentration and the pathophysiology of dysnatremias
Kidney International
(2005) - et al.
Hyponatremia and hyperkalemia in relation to hyperglycemia in insulin-treated diabetic out-patients
Clinica Chimica Acta
(1982) - et al.
Lethal hyperkalemia associated with severe hyperglycemia in diabetic patients with renal failure
American Journal of Kidney Diseases
(1985)
Altered pulmonary capillary permeability complicating recovery from diabetic ketoacidosis
Chest
Pulmonary edema. A complication of diabetic ketoacidosis
Chest
Effects of hyperglycemia on serum sodium concentration and tonicity in outpatients on chronic dialysis
American Journal of Kidney Diseases
Acid–base disorders in hyperglycemia of insulin-dependent diabetic patients on chronic dialysis
The Journal of Diabetic Complications
Review: Diabetic ketoacidosis and hyperglycemic hyperosmolar nonketotic syndrome
American Journal of Medicine Science
Metabolic findings in hyperosmolar non-ketotic diabetic stupor
Lancet
Hypernatremia
New England Journal of Medicine
Extreme hyperglycemia in dialysis patients
Clinical Nephrology
Nonketotic hyperosmolar coma with hyperglycemia
Medicine (Baltimore)
On diabetic acidosis: A detailed study of electrolyte balances following the withdrawal and reestablishment of insulin therapy
Journal of Clinical Investigation
Response of congestive heart failure to correction of hyperglycemia in the presence of diabetic nephropathy
New England Journal of Medicine
Severe diabetic ketoacidosis (diabetic “coma”)
Diabetes
Diabetic ketoacidosis and cerebral edema
Current Opinion in Pediatrics
Diabetic acidosis, a transition
Penn Med
Hyperglycemia and hyperosmolality complicating peritoneal dialysis
Annals of Internal Medicine
Recurrent high-permeability pulmonary edema associated with diabetic ketoacidosis
Critical Care Medicine
Metabolic studies in diabetic coma
Trans Soc Am Phys
Diabetic acidosis: An evaluation of the cause, course and therapy of 73 cases
Annals of Internal Medicine
Hyperosmolar and other types of ketoacidotic coma in diabetes
Diabetes
Hyperosmolar coma: Cellular dehydration and the serum sodium concentration
Annals of Internal Medicine
Severe degrees of hyperglycemia: Insights from integrative physiology
Quarterly Journal of Medicine
The importance of serum sodium in the symptomatology of hyperglycemic-induced hypertonicity
Journal of Nephrology
Nonketotic hyperosmolar diabetic pre-coma due to pancreatitis in a boy on continuous ambulatory peritoneal dialysis
Nephron
The hypertonic states
New England Journal of Medicine
Why do patients with diabetic ketoacidosis have cerebral swelling, and why does treatment sometimes make it worse?
Pediatrics & Adolescent Medicine
Drinking in nephrectomized rats injected with various substances
Journal de Physiologie
Fluid and electrolyte complications of peritoneal dialysis
Annals of Internal Medicine
Clinical and metabolic characteristics of the hyperosmolar nonketotic coma
Diabetes
The hyperglycemic hyperosmolar syndrome
American Journal of Medicine Sciences
Cited by (31)
Management of diabetic ketoacidosis
2023, European Journal of Internal MedicineManagement of diabetic ketoacidosis in special populations
2021, Diabetes Research and Clinical PracticeCitation Excerpt :It is important to note that serum bicarbonate can be normal or only mildly reduced and the main marker for DKA is a high anion gap, generally more than 20 mEq/L. Furthermore, the usually marked hypovolaemia and electrolyte depletion in DKA are generally attenuated in patients with chronic kidney disease [15]. Hyperglycaemia leading to osmotic shift of fluid from the intracellular to the extracellular compartment, high serum tonicity and increased thirst and water intake will cause extracellular volume expansion leading to lower extremity and pulmonary oedema and elevated blood pressure [16]. Defects in water and electrolyte excretion in these patients can lead to hyponatraemia, hyperkalaemia and hyperphosphataemia.
Management of extracellular volume in patients with end-stage kidney disease and severe hyperglycemia
2020, Journal of Diabetes and its ComplicationsSymptomatic Hyperglycemia in a Patient with Dialysis Ascites
2019, American Journal of the Medical SciencesCitation Excerpt :Since hyperglycemia in oligo-anuric patients is not associated with significant fluid loss through osmotic diuresis and can be effectively treated with insulin infusion,5 this clinical condition provides an opportunity to test the accuracy of Katz's formula. A review of published reports of dialysis-associated hyperglycemia treated with insulin confirmed both the presence of hyponatremia at hyperglycemia and the accuracy of Katz's formula in the majority of cases.6 Herein, we present a patient on maintenance hemodialysis who rapidly developed extreme hyperglycemia with severe neurological manifestations.
Indices of serum tonicity in clinical practice
2015, American Journal of the Medical SciencesCitation Excerpt :Studies in patients receiving chronic dialysis who presented with hyperglycemia and who were treated with insulin only and had minimal or no diuresis confirmed the validity of Katz’s calculations. A review that analyzed 6 studies of 148 hyperglycemic patients on chronic dialysis who were treated with insulin computed an average coefficient α of 0.016 ± 0.004 mmol/L per mg/dL.26 Sequential calculations of the corrected [Na]S were performed using a coefficient α of 0.016 in patient 3 of this report, who was treated only with insulin infusion.
Diabetic Ketoacidosis and Hyperglycemic Hyperosmolar State
2013, Endocrinology and Metabolism Clinics of North America